Initial Comments:
This report is the result of a State Relicensure survey conducted onsite on November 9 and on November 13, 2023 , at Lvhn Surgery Center-Tilghman. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.
Plan of Correction:
51.31 LICENSURE
Exceptions - Principle
Name - Component - 00
51.31. Principle
The Department may grant exceptions to this part when the policy and objectives contained therein are
otherwise met, or when compliance would create an unreasonable hardship and an exception would not impair or endanger the health, safety or welfare of a patient or resident. No exceptions or departures from this part will be granted if compliance with the requirement is provided for by statute.
Observations:
Based on a review of Credential Files (CF) and interview with staff (EMP), it was determined the facility failed to adhere to the Division of Acute and Ambulatory Care (Department) requirements for an Exception Request granted for the use of surgical skin preparations that contain combustible agents by failing to ensure physicians involved in the use of surgical skin preparations that contain combustible agents/explosive hazards participated in annual mandatory education as required by the Department for three of three CF's reviewed (CF1, CF2 & CF3).
Findings include:
A review on November 9, 2023, of a letter from the Department dated January 16, 2014, revealed "...The Department of Health is in receipt of your request for an exception to 28 Pa. Code 569.35 (7), relating to regulations for control of anesthetic explosion hazards. You have completed the process established by the Department for requesting an exception to this regulation and agreed to the following: The facility shall institute annual mandatory education provided to all staff, including the physician staff, involved in the use of surgical skin preparations that contain combustible agents. The content of the education provided and documentation of same will be reviewed by the Department during survey activity....Your request is approved..."
Review on November 9, 2023 of CF1 revealed no doucmentation of annual alcohol based preparation mandatory education.
Review on November 9, 2023 of CF2 revealed no doucmentation of annual alcohol based preparation mandatory education.
Review on November 9, 2023 of CF3 revealed no doucmentation of annual alcohol based preparation mandatory education.
A request was made on November 9, 2023 at approx. 2 PM to EMP1 for the annual mandatory education for annual alcohol based preparation mandatory education "ChloraPrep" (use of surgical skin preparation that contain combustible agents/explosive hazards), for the physician staff. None was provided.
An interview conducted on November 9, 2023 at 2:15 PM with EMP1 confirmed none of the physician staff attended the training in the use of surgical skin preparations that contain combustible agents/explosive hazards.
Plan of Correction:1. Physician staff education plan was developed pertaining to the use of surgical skin alcohol-based preparations. This education plan is being provided to all surgical physicians that provide services at the LVHN Surgery Center - Tilghman. The education will be conducted in person at the facility by: Administrator, Director of Nursing or Patient Care Specialist.
a. Surgical Skin Alcohol-Based Preparation education was implemented on November 10, 2023. This education was delivered in person to the providers upon their arrival to LVHN Surgery Center - Tilghman facility.
b. The 2023 education will be conducted daily and monitored weekly until all providers are educated.
2. Surgical Skin Alcohol-Based Preparation education will have a annual mandated completion date of the end of each fiscal year's 2nd quarter (December 31st).
a. Providers not currently educated will be informed of the new annual mandatory education and its process via LVHN email by December 11, 2023. This email will state their responsibility to have this education upon their next arrival at the facility. The email will require an electronic read receipt.
3. The annual physician education completion status will be monitored monthly and reported at the LVHN Surgery Center – Tilghman quarterly QI/PI meeting to maintain compliance beginning December 28, 2023.
a. The Administrator, Director of Nursing or Patient Care Specialist will monitor and report the completion status at each fiscal year 3rd quarter meeting or during the months of January, February, and March.
4. LVHN Surgery Center - Tilghman Administrator will be responsible for execution of Plan of Correction.
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